It is completely automated and therefore extremely rigid. TULSA has been proposed as a localized treatment of unilateral intermediate risk prostate cancers in individuals not interested in active surveillance (Klotz, 2021). In Ohio: Community Insurance Company. Revised June 27, 2022. In a systematic review, Li and colleagues (2014) performed a meta-analysis on the use of HIFU in combination with radiotherapy or chemotherapy in the treatment of pancreatic cancer. MPTAC review. Uddin Ahmed H, Cathcart P, Chalasani V, et al. This LCD supplements but does not replace, modify or supersede existing Medicare applicable National Coverage Determinations (NCDs) or payment policy rules and regulations for Ultrasound, Soft Tissues of Head and Neck. 2011; 185(4):1246-1254. * Make sure your health is protected with an Individual and Family plan you can count on in 2023. Uchida T, Baba S, Irie A, et al. Centers for Disease Control and Prevention (CDC). 2009; 101(1):19-26. Due to variances in utilization patterns, each plan may choose whether to adopt a particular Clinical UM Guideline. Br J Surg. In addition, eligible participants reported a numerical rating scale (NRS) pain score of 4 or greater in spite of maximal pain medication therapy, and a score of 7 or less on the Mirels fracture risk scale. Available at: High Intensity Ultrasound System For Prostate Tissue Ablation (Focal One). MPTAC review. In November, the FDA approved the use of Ablatherm (Maple Leaf; Toronto, Canada) to treat prostate cancer in individuals who previously failed radiation therapy. Under the benefits of certain plans, the following diagnostic imaging services that are received in an outpatient setting, such as in a medical office, the outpatient department of a hospital or at a freestanding imaging center may require prior approval (for dates of service on or after February 15, 2007 for Blue Cross NC commercial plans and September 1, 2010 for Blue Medicare HMO and Blue . Ultrasound examinations, particularly if obtained soon after onset of infection, may not identify prenatal features of congenital Zika syndrome and structural manifestations can be identified at later points in pregnancy. Summary of Safety and Effectiveness Data (SSED). Uchida T, Tomonaga T, Kim H, et al. MPTAC review. 2017. Comprehensive medical coverage that covers many common services at no cost or for a low copay. This study was a retrospective case series involving 804 subjects who underwent HIFU and were included in an industry-sponsored registry. Note: Please see the following related document for additional information: Maternity ultrasound is considered medically necessary for any of the following: Maternity ultrasound is considered not medically necessary for: The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Beerlage HP, Thuroff S, Debruyne FM, et al. Blana A, Murat FJ, Walter B, et al. MPTAC review. Prostate Cancer. Kaur A, Kaur A. Transvaginal ultrasonography in first trimester of pregnancy and its comparison with transabdominal ultrasonography. Systematic review of innovative ablative therapies for the treatment of locally advanced pancreatic cancer. Updated References. While the National Comprehensive Cancer Network (NCCN) Clinical Practice Guidelines (CPG) in Oncology for Adult Cancer Pain (V2.2022) document notes that the palliative effects of HIFU have been demonstrated in several small studies, no recommendation for or against the use of HIFU for pain palliation was given. 2013; 63(2):395-398. Contact us today for information about Anthem or for questions regarding Medicaid programs and coverage. MR-guided focused ultrasound (MRgFUS) ablation for the treatment of nonspinal osteoid osteoma: a prospective multicenter evaluation. BJU Int. Influence of high intensity focused ultrasound (HIFU) treatment to the pancreatic function in pancreatic cancer patients. One of the largest of these studies was conducted by Ganzer and colleagues (2011). CPT Only - American Medical Association, MED.00057 MRI Guided High Intensity Focused Ultrasound Ablation for Non-Oncologic Indications, CG-SURG-61 Cryosurgical, Radiofrequency or Laser Ablation to Treat Solid Tumors Outside the Liver, https://acsearch.acr.org/docs/69397/Narrative, https://www.auanet.org/guidelines-and-quality/guidelines/renal-mass-and-localized-renal-cancer-evaluation-management-and-follow-up, https://www.astro.org/uploadedFiles/_MAIN_SITE/Patient_Care/Clinical_Practice_Statements/Content_Pieces/ClinicallyLocalizedProstateCancer.pdf, https://www.accessdata.fda.gov/cdrh_docs/pdf15/k153023.pdf, https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm?ID=K172721, https://www.accessdata.fda.gov/cdrh_docs/pdf19/K191200.pdf, https://www.accessdata.fda.gov/cdrh_docs/pdf11/p110039b.pdf, http://www.cancer.org/treatment/understandingyourdiagnosis/bonemetastasis/bone-metastasis-treating-problems-caused, http://www.cdc.gov/cancer/prostate/basic_info/treatment.htm, https://medlineplus.gov/prostatecancer.html, https://www.nlm.nih.gov/medlineplus/palliativecare.html. Joo B, Park MS, Lee SH, et al. PLoS One. We reserve the right to review and update Clinical UM Guidelines periodically. The majority of events were minor and reversible. The document header wording updated from Current Effective Date to Publish Date. Updated Discussion/General Information, References and Websites for Additional Information sections. Eur Urol. Dupr A, Melodelima D, Prol D, et al. That coverage comes at a cost, however; specifically, Plan F is the most expensive of all the MedSup policies on the market today. Poggenpoel EJ, Geerts LT, Theron GB. Updated Coding section to add ICD-10-CM diagnosis codes O09.00-O09.03, O09.811-O09.829. August 15, 2019. There was 1 in-field and 2 out-of-field recurrences reported at that time. We are now accepting all Anthem Blue Cross Blue Shield patients. Available at: U.S. National Library of Medicine. Revised title from High Intensity Focused Ultrasound (HIFU) for Oncologic Indications to Ultrasound Ablation for Oncologic Indications. Visit our official site today for more details. Yonsei Med J. Available at: Centers for Disease Control and Prevention (CDC): How is Prostate Cancer Treated? Blana A, Walter B, Rogenhofer S, Wieland WF. Cancer. High-intensity focused ultrasound (HIFU) followed after one to two weeks by radical retropubic prostatectomy: results of a prospective study. Relief of lower urinary tract symptoms after MRI-guided transurethral ultrasound ablation for localized prostate cancer: subgroup analyses in patients with concurrent cancer and benign prostatic hyperplasia. Breast MRI costs an average $615 under Medicare . The mean reduction in the NRS score was significant between MRgFUS and placebo (3.6 3.1 versus 0.7 2.4). Pickles T, Goldenberg L, Steinhoff G. Technology review: high-intensity focused ultrasound for prostate cancer. 2016; 47(4):530-532. Accessed on October 20, 2022. 2004; 63(4):625-629. The maternal cervix and adnexa should be examined. Added not medically necessary statement for TULSA. When a growth disturbance is suspected clinically or there is a medical or obstetric condition that increases the risk of a growth disturbance, ultrasonography is the modality of choice to identify abnormal fetal growth. The majority of attributable AEs were grade 1 or 2. AIUM Practice Parameter for the Performance of Detailed Diagnostic Obstetric Ultrasound Examinations Between 12Weeks 0Days and 13Weeks 6Days. However, comparisons involving HIFU were limited to radical prostatectomy because of a lack of studies comparing HIFU to other therapies. The doctors in the emergency room did multiple tests including a CT scan and ultrasound. 2018. Sonablate was classified as a class II device. In some states, insurance must cover . Ganzer R, Robertson CN, Ward JF, et al. For instance, if you want to take advantage of inversion therapy, massage, ultrasound therapy, or computer-assisted adjustments, youll need to ask your insurance company about the availability of coverage for these things . The use of high intensity focused ultrasound (HIFU) is considered medically necessary for pain palliation in individuals with localized metastatic bone pain when all the following criteria are met: High intensity focused ultrasound (HIFU) is considered not medically necessary when the above criteria are not met and for all other indications, including but not limited to, the treatment of prostate cancer. NOTE: Information about the cost of this plan (called the premium) will be . 2014; 11(6):303. Cancer. MPTAC review. HIP Maternity will cover enhanced benefits . For more information about your rights, look at the explanation of benefits you will receive for that medical claim. First clinical experience of intra-operative high intensity focused ultrasound in patients with colorectal liver metastases: a phase I-IIa study. 2012; 118(12):3071-3078. Muto S, Yoshii T, Saito K, et al. Clin Orthop Relat Res. Birth Defects Homepage: Diagnosis. Rejection notice to me (if I'm lucky) and I start over. In the 25 participants that were able to tolerate a complete treatment, 72% (18/25) reported significant pain reduction of at least 2 points on the VAS scale, 24% (6/25) reported no reduction in pain and 4% (1/25) reported an increase in pain levels. Magnetic resonance imaging-guided transurethral ultrasound ablation of prostate cancer. Kenkhuis MJA, Bakker M, Bardi F, ET AL. Alternatively, commercial or FEP plans or lines of business which determine there is not a need to adopt the guideline to review services generally across all providers delivering services to Plans or line of businesss members may instead use the clinical guideline for provider education and/or to review the medical necessity of services for any provider who has been notified that his/her/its claims will be reviewed for medical necessity due to billing practices or claims that are not consistent with other providers, in terms of frequency or in some other manner. Ultrasound imaging can be used after delivery to evaluate abnormalities of the reproductive and adjacent structures. A clinically significant biopsy was reported in 34% (10/29) of participants with 59% (17/29) of participants reporting any positive biopsy. Clin Orthop Relat Res. AIUM Practice Parameter for the Performance of Limited Obstetric Ultrasound Examinations by Advanced Clinical Providers. grievance or appeal. . Geiger D, Napoli A, Conchiglia A, et al. Reaffirmed October 2021. HIFU has been proposed as a treatment for multiple oncologic conditions. Post-treatment biopsies were available in 77% of subjects. High intensity focused ultrasound (HIFU): A surgical procedure that uses focused high energy sound waves to destroy target tissues in the body. Bone Metastases. Clinical guidelines approved by the Medical Policy & Technology Assessment Committee are available for general adoption by plans or lines of business for consistent review of the medical necessity of services related to the clinical guideline when the plan performs utilization review for the subject. Prostate cancer is the most commonly diagnosed cancer in men, accounting for 19% of all new cancer cases. Reformatted Coding section. Yutkin V, Ahmed HU, Donaldson I, et al. Radiother Oncol. MPTAC review. Reaffirmed 2018. 2010; 17(8):715-719. Available at. High Intensity Ultrasound System For Prostate Tissue Ablation (Ablatherm). Added medically necessary indication when there is a known or suspected exposure to the Zika virus to the Clinical Indications section. Previously, this recommendation was graded as a 2A. Crouzet S, Chapelon JY, Rouvire O, et al. Federal and State law, as well as contract language, and Medical Policy take precedence over Clinical UM Guidelines. ACOG Practice Bulletin Number 183, October 2017. Indiana Medicaid for Members. MPTAC review. Anthem becomes the third national payor to cover the treatment after Aetna and Blue Cross Blue Shield Association gave it positive coverage decisions in April 2021 and August 2018,. One ultrasound of a pregnant uterus per member, per routine course of care; Estimate gestational age for individuals with uncertain clinical dates. The price of a diagnostic mammogram averages from $172 under Medicare to $239 with private insurance. Nair SM, Hatiboglu G, Relle J, et al. $15 UK HEALTHCARE PRIMARY CARE CO-PAY $25 ANTHEM PRIMARY CARE CO-PAY $40 Specific findings associated with congenital Zika syndrome include intracranial calcifications, microcephaly, ventriculomegaly, arthrogryposis; abnormalities of the corpus callosum, cerebrum, cerebellum, and eyes; and other brain abnormalities. The following codes for treatments and procedures applicable to this guideline are included below for informational purposes. Focal salvage therapy for localized prostate cancer recurrence after external beam radiotherapy: a pilot study. Temperatures within the targeted area increase to 60-95C, which destroys the targeted tissue without damaging the adjacent tissue. Anthem Member Services 1-855-690-7784 (TTY 711) Monday through Friday, 7 a.m. to 7 p.m. Care on Call 1-866-864-2544 (TTY 711) Answers to your medical questions any time, night or day Behavioral Health Crisis Hotline. 1999b; 39(1):41-46. Clinical guidelines approved by the Medical Policy & Technology Assessment Committee are available for general adoption by plans or lines of business for consistent review of the medical necessity of services related to the clinical guideline when the plan performs utilization review for the subject. Ultrasound imaging, also called ultrasound scanning or sonography, is a method of obtaining images of internal organs by sending high-frequency sound waves into the body. In the December 2013 issue of Network Update, you were notified of the following: For claims with dates of service on or after March 17, 2014, Anthem Blue Cross and Blue Shield (Anthem) in Indiana, Kentucky, Missouri, Ohio and Wisconsin (individually referred to herein as the Health Plan), will no longer reimburse CPT code 76942 (Ultrasonic . The five HIFU trials included a total of only 136 individuals. In the absence of specific indications, the optimal time for a single ultrasound examination is at 1822 weeks of gestation. Chin JL, Billia M, Relle J, et al. MedlinePlus. TULSA was developed as an alternative method of prostate tissue ablation. Chaussy C, Thuroff S. Results and side effects of high-intensity focused ultrasound in localized prostate cancer. Retroperitoneal ultrasound (US) studies represent the ultrasonic imaging of retroperitoneal organs for the diagnosis and management of abnormalities that occur within the retroperitoneum. ACOG Practice Bulletin 163. Indiana Medicaid. ACOG Practice Bulletin Number 171. The recommendations are based on limited data. At 3 months, 72.2% (13/18) reported no pain without the use of pain medication, and 16.7% (3/18) reported a drop of at least 2 points on pain scale without an increase in pain medication. Review January 10, 2022. Prostate Cancer Prostatic Dis. Pain palliation for localized metastatic bone pain. In 2021, Nair and colleagues reported the 3-year outcomes of the participants in the Chin study. Urology. 2012; 118(17):4148-4155. In 2015, The U.S. Food and Drug Administration (FDA) approved two devices for use in prostate cancer. Magnetic resonance-guided focused ultrasound for patients with painful bone metastases: phase III trial results. Updated Discussion/General Information, Coding and Reference sections. Locally recurrent prostate cancer after initial radiation therapy: early salvage high-intensity focused ultrasound improves oncologic outcomes. 2000; 4(3):183-187. AIUM practice guideline for the performance of obstetric ultrasound examinations. Before you decide to pass on Plan F, though, do your due diligence and see how much the insurance . Addition of cell-free fetal deoxyribonucleic acid (DNA) screening for aneuploidy to Medically Necessary Statement. Curr Urol Rep. 2003; 4(3):248-252. Available at: Second and third trimester screening for fetal anomaly. HIFU is a non-invasive ablative procedure which has the advantage of sparing surrounding tissue which may reduce postoperative morbidity and hasten recovery. Rebillard X, Gelet A, Davin JL, et al. October 2016. Focused ultrasound for the treatment of bone metastases: effectiveness and feasibility. BJU Int. While there is no reliable evidence to support ultrasounds performed during pregnancy will harm a fetus, there is general agreement that the casual use of ultrasonography during pregnancy should be avoided (ACOG, 2018). According to the FDA labeling, a nonunion is considered to be established when the fracture site shows no visibly progressive signs of healing. The current evidence is insufficient to support the use of HIFU as a generally accepted oncological treatment. Control of prostate cancer by transrectal HIFU in 227 patients. $0 virtual care, 24/7. Known or suspected abnormality of placenta: Assess placental location associated with vaginal bleeding; Suspected abnormal placental attachment (placenta accreta); Suspected retained placenta or products of conception. 2015; 102(8):873-882. Pregnant Women. Thompson I, Thrasher JB, Aus G, et al. Gelet A, Chapelon JY, Poissonnier L, et al. MPTAC review. Placenta Accreta Spectrum. Ultrasound examinations can be used to assess fetal anatomy, particularly neuroanatomy, and to monitor growth. However, residual tumors of less than 10% were found in 29.4% of cases and residual tumors between 10-90% were found in 22.7% of cases. The authors reported technically precise results and showed that the treatment can be targeted within a narrow range. Prostate Cancer (V1.2023). AIUM-ACR-ACOG-SMFM-SRU Practice parameter for the performance of standard diagnostic obstetric ultrasound examinations. 2014; 84(5):1157-1162. July 23, 2021. Available at: Second and Third Trimester Vaginal Bleeding. close combat footage enemy visible bungee fitness dickson tn Tue, Oct 18 2022 The baseline median PSA of 7.6 ng/ml decreased to 0.23 ng/ml at 12 months follow-up. The difference in response rates between MRgFUS and placebo at 3 months was significant (64.3% versus 20.0%). Medical Encyclopedia. Magnetic resonance imaging-guided transurethral ultrasound ablation of prostate tissue in patients with localized prostate cancer: a prospective Phase 1 clinical trial. 2014; 106(5). The sound wave echoes are recorded and displayed as a real-time visual image. In addition, there are limitations on tissue tolerance at sites previously irradiated. Re: Salvage high-intensity focused ultrasound for patients with recurrent prostate cancer after brachytherapy. Ultrasound Obstet Gynecol. There's Still Time To Enroll $0 preventive care. Harding D, Giles SL, Brown MRD, et al. These adjustments apply to members of Commercial business, including self-insured plans, Medicare, and Medi-Cal business. Updated Discussion/General Information, References and Websites for Additional Information sections. 2021; 35(4):497-505. Focal therapy for localized prostate cancer: a phase I/II trial. Available at: High Intensity Ultrasound System for Prostate Tissue Ablation (TULSA-PRO System). ACOG Practice Bulletin 175. Quality of life following high-intensity focused ultrasound for the treatment of localized prostate cancer: a prospective study. Nat Clin Pract Urol. Subtle second-trimester ultrasound markers should be interpreted in the context of a background risk based on the patients age, history, genetic screening, and serum screening results. In a phase 1, single-arm, prospective study, Chin and colleagues (2016) evaluated the safety and feasibility of MRI guided TULSA. 2018; 74(4):422-429. Urology. Prostate cancer therapy with high-intensity focused ultrasound. Bertrand AS, Iannessi A, Natale R, et al. Update date: March 4, 2022. 2012; 116(3):201-205. 2017; 197(1):97-102. Crouzet S, Blana A, Murat FJ, et al. To determine if review is required for this Clinical UM Guideline, please contact the customer service number on the member's card. . Location: Tuba City<br>We currently have a client in Tuba City, AZ looking for a Licensed Ultrasound Technologist!<br><br>Focus Staff is seeking a traveling Licensed Ultrasound Technologist to perform ultrasound procedures on ambulatory and hospital patients in a physician office, clinic, and hospital setting as requested by a physician or other licensed provider for the diagnosis of disease . Eur Urology. 2015 Mar;34(3):435-440. June 7, 2018. Available at: ACOG. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member. 2014; 114(4):532-540. New reimbursement policy: Maternity Services and Multiple Delivery (Professional) Beginning with dates of service on or after December 1, 2019, Anthem's current Routine Obstetrics policy will be retired and will be replaced by the new Maternity Services policy and the new Multiple Delivery policy. American College of Obstetricians and Gynecologists (ACOG). Anttinen and associates (2020) evaluated TULSA use as a partial salvage therapy in individuals with localized, recurrent prostate cancer. TULSA is delivered by a system which includes real-time MR thermometry as well as robotically-driven directional thermal ultrasound in a closed loop system to ablate whole gland or targeted areas of the prostate. 2015; 2015(6):CD001451. New 2020. Evaluation of quality of life outcomes following palliative treatment of bone metastases with magnetic resonance-guided high intensity focused ultrasound: an international multicentre study. 15727 Anthem Pkwy, Suite 600 . An obstetrical ultrasound in the second or third trimester includes an evaluation of fetal number, cardiac activity, presentation, amniotic fluid volume, placental position, fetal biometry, and an anatomic survey. 2014; 20(28):9570-9577. There were no new reported serious AEs. MRI-TULSA resulted in an 88% reduction of viable prostate tissue volume. Whole-gland ablation of localized prostate cancer with high-intensity focused ultrasound: oncologic outcomes and morbidity in 1002 patients. Salvage high-intensity focused ultrasound for patients with recurrent prostate cancer after brachytherapy. Updated Coding section; added ICD-10-CM code ranges O98.111-O98.119, O99.310-O99.313, O99.320-O99.323, O99.330-O99.333. High-intensity focused ultrasound and localized prostate cancer: efficacy results from the European multicentric study. CO CHEIBA Custom Blue Priority PPO/BluePreferred Plan F 01 -20 1 of 15 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 01/01/2021- 12/31/2021 Anthem Blue Cross and Blue Shield: Prime Blue Priority PPO 2021. Focal high intensity focused ultrasound of unilateral localized prostate cancer: a prospective multicentric hemiablation study of 111 patients. Late complications included occurrences of stenosis (9%) and fistula (0.4%). High intensity focused ultrasound ablation for patients with inoperable liver cancer. Shoji S, Nakano M, Nagata Y, et al. The uterus, cervix, adnexa, and cul-de-sac region should be examined. Transrectal high-intensity focused ultrasound in the treatment of localized prostate cancer. Rooms for rent in Bury flat and house shares - 3 currently available. Zip Code or City, State . HAIFA, Israel- MIAMI, Dec. 22, 2022/CNW/ -- Insightec, a global healthcare company dedicated to using acoustic energy to transform patient care, announced today that Anthem is the third national. Focal therapy with high-intensity-focused ultrasound in the treatment of localized prostate cancer. The SBC shows you how you and the plan would share the cost for covered health care services. The limited examination of small biopsies as well as the lack of a reliable means of assessing some prognostic factors, such as potential lymphovascular invasion, may not provide adequate information for the determination of adjuvant systemic therapies. For other common visits, this is what you'll pay with PPO. Bonekamp D, Wolf MB, Roethke MC, et al. A total of 29 individuals underwent a follow-up biopsy, either at 12 months only, or at 12 and 36 months. Available at: Testing for Zika Virus Infections. 1000s more rooms to let in Bury, West Sussex and across the UK at SpareRoom.co.uk - the UK's #1 flatshare site. Updated Description, Discussion and References sections. CA/IND/Anthem Silver 73 HMO/657G/01-22 Page 1 of 12 Summary of Benefits and Coverage: What this Plan Covers & What You Pay for Covered ServicesCoverage Period: 01/01/2022 - 12/31/2022 Anthem BlueCross Coverage for: Individual + Family | Plan Type: HMO Anthem Silver 73 HMO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. PSA nadir as a predictive factor for biochemical disease-free survival and overall survival following whole-gland salvage HIFU following radiotherapy failure. *Coverage includes fertility preservation . Updated: June 16, 2022. In the obese patient, expectations regarding visualization of fetal anatomy should be tempered. 2018; 30(4):233-242. J Endourol. Uchida T, Ohkusa H, Nagata Y, et al. ; AUA Prostate Cancer Clinical Guideline Update Panel. But in general, know that most plans cover: STD testing; Rh incompatibility testing; Prenatal vitamins; Gestational diabetes testing; Breastfeeding counseling and equipment; Post-birth birth control; Birth; Medical coverage of any complications; Dependent Care Accounts MedlinePlus. J Urol. The location you tried did not return a result. Anthem Blue Cross and Blue Shield - BlueAdvantage POS Colorado Higher Education Insurance Benefits Alliance Trust Coverage for: Individual + Family | Plan Type: HMO . Boccon-Gibod L, Djavan WB, Hammerer P, et al. 2021; 205(3):769-779. Experience of intra-operative high intensity focused ultrasound ( MRgFUS ) ablation for oncologic anthem ultrasound coverage Detailed diagnostic Obstetric ultrasound can! Comparisons involving HIFU were limited to radical prostatectomy because of a lack of studies comparing to... Focal one ) please contact the customer service number on the member 's card a predictive factor for disease-free... And Websites for Additional Information sections following radiotherapy failure in-field and 2 out-of-field reported. Of gestation and morbidity in 1002 patients fetal deoxyribonucleic acid ( DNA ) screening for to... Delivery to evaluate abnormalities of the participants in the absence of specific Indications, the U.S. Food and Drug (! Adopt a particular Clinical UM Guidelines ( DNA ) screening for aneuploidy to medically necessary when. Monitor growth colleagues ( 2011 ) the use of HIFU as a treatment for multiple conditions. Involving HIFU were limited to radical prostatectomy because of a diagnostic mammogram averages from $ 172 under.! & # x27 ; ll pay with PPO a single ultrasound examination is at 1822 weeks of.... Uterus per member, per routine course of care ; Estimate gestational age for individuals with Clinical. 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